ObjectivesThe aim is to explore the effects of antecedent, structural and process quality indicators of nutritional care practice on meal satisfaction and screened nutritional status among older adults in residential care homes.DesignData for this Swedish cross-sectional study regarding older adults living in residential care homes were collected by i) a national questionnaire, ii) records from the quality registry Senior Alert, iii) data from an Open Comparison survey of elderly care in 2013/2014. The data represented 1154 individuals in 117 of 290 Swedish municipalities.MeasurementsMeal satisfaction (%) and adequate nutritional status, screened by the Mini Nutritional Assessment Short Form (MNA-SF), were the two outcome variables assessed through their association with population density of municipalities and residents’ age, together with 12 quality indicators pertaining to structure and process domains in the Donabedian model of care.ResultsMeal satisfaction was associated with rural and urban municipalities, with the structure quality indicators: local food policies, private meal providers, on-site cooking, availability of clinical/community dietitians, food service dietitians, and with the process quality indicators: meal choice, satisfaction surveys, and ‘meal councils’. Adequate nutritional status was positively associated with availability of clinical/community dietitians, and energy and nutrient calculated menus, and negatively associated with chilled food production systems.ConclusionMunicipality characteristics and structure quality indicators had the strongest associations with meal satisfaction, and quality indicators with local characteristics emerge as important for meal satisfaction. Nutritional competence appears vital for residents to be well-nourished.

National actions such as soft governance and benchmarking appear largely to determine local level outcomes. However, conditions for adapting these measures vary between municipality groups. While efficiency enhancing trends were prominent, questions remain whether national actions should be expanded beyond performance to also examine their consequences.

Guided by the i-PARIHS framework, this study investigates perceived facilitators in the process of adopting a new regulation launched in 2015 which aims to prevent and treat malnutrition. In May 2016, a national web-based questionnaire was emailed to chief medical nurses in elderly care in all Swedish municipalities (n = 290). The response rate in this cross-sectional study was 75% (n = 217). Fifty per cent of the municipalities had adopted new routines, 42% had started and 8% had not. One third of the respondents considered malnutrition to be a major problem in elderly care and about half considered the new national regulation to have strengthened local work. A logistic regression showed that the odds for having adopted new routines were higher for CMNs with long experience in elderly care and who had previously worked to prevent malnutrition, and for those who considered the new national regulation helpful. To extract underlying factors in the adoption process, two principal component analyses were performed for key actors and support. For key actors, the analysis yielded four factors, explaining 67% of the total variance; (a) first line team, (b) expert team, (c) management team and (d) surrounding resources. For support, the analysis yielded three factors, which explained 65% of the total variance; (a) agile teamwork, (b) management and leadership and (c) acceptance. The slow adoption rate of the regulation raises questions about its impact; this might be an effect of the general trend of decentralisation in the Swedish welfare sector, and in elderly care in particular, making it hard to attain change that is steered centrally. However, malnutrition is a pronounced problem in elderly care and the mandatory nature of the new regulation therefore warrants further investigation of whether its launch has contributed to a reduction of malnutrition by investigating outcomes and preventive actions carried out in practice.

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